case masswe colonic haemorrhage from asolitary caecal...

HPB Surgery, 1996, Vol.9, pp.253-256Reprints available directly from the publisherPhotocopying permitted by license only

(C) 1996 OPA (Overseas Publishers Association)Amsterdam B.V. Published in The Netherlands

by Harwood Academic Publishers GMbHPrinted in Malaysia

MassweCASE REPORT

Colonic Haemorrhage from aCaecal Varix

Solitary

K. R. L. SHAPER, M. JARMULOWICZ*, R. DICK+, N. D. CUTHBERTand B. R. DAVIDSON

Departments of Surgery, *Histopathology and +Radiology, Royal Free Hospital, Pond Street,Hampstead, London NW3 2QG

(Received 20 January 1994)

A 51 year old lady with chronic active hepatitis presented with massive lower gastrointestinal tract bleeding.Angiography demonstrated a solitary varix in the caecum which was found at laparotomy to be entering thebowel wall at the site ofadhesions from a previous appendicectomy. The portal pressure was found to be raised.A right hemicolectomy stopped the blood loss, but she subsequently died ofliver failure. Solitary colonic varicesassociated with adhesions are extremely rare and their optimal management has not been established.

KEY WORDS: Colonic bleeding varices

INTRODUCTION

Bleeding from colonic varices is rare, but is recognisedas a complication of portal hypertension. A recentreview documented 127 cases in the literature 1. Co-Ionic varices are usually multiple and may occurthrough adhesions at the site of previous surgery2. Wereport a unique case of massive colonic bleeding froma solitary varix at the site of an appendicectomy.

CASE REPORT

A 51 year old lady was admitted to hospital withprofuse flesh rectal bleeding. She had a history ofchronic active hepatitis diagnosed in 1973 on liverbiopsy and was maintained on Prednisolone 5mg andSpironolactone 100mg daily. Her past medical historyincluded an appendicectomy at the age of fourteen.On admission she was shocked, with pulse of 130

per min and an unrecordable blood pressure.

Correspondence to: B.R. Davidson, Department of Surgery, RoyalFree Hospital, Pond Street, London. NW3 2QG.

Blood tests revealed Hb 8.6 g/dl(11.5-15.5), WCC12.8(4.5-11), Platelets 111(140-500), Urea 5.7mmol/1

(3-6.5), Na 153mmol/1 (135-145), K 5.7mmol/1 (3.5-5.0), Bilirubin 12.0 mcmol/l(5-17), Albumen 24g/1(35-50), ALP69u/l(35-130), AST 4lull (5-40), ALT35u/1(5-40), PT 41 sec (12-16), PTTK 154 sec (30-40), INR 4.8, FDP<0.5 (2-4).

Active resuscitation was commenced and agastroscopy was performed. No blood was seen in thestomach or duodenum and there was no evidence ofoesophageal varices. Mesenteric angiography wasthen undertaken to delineate the source of bleeding.This revealed a large, anomalous vein running fromthe region of the caecum, laterally in the right para-colic gutter, up to the inferior vena cava [Figs. &2].The portal vein was patent and there were no varicesat other sites. The spleen was of normal size. Atechnetium labelled red cell scan confirmed that thebleeding was from the right side of the abdomen.Despite rapid transfusion and clotting factor replace-ment, the bleeding continued and a laparotomy wasperformed. At operation the liver was noted to becirrhotic. The colon was distended with blood whichwas also present in the terminal ileum. Adhesions werefound between the abdominal wall and caecum at thesite of her previous appendicectomy and running

253

254 K.R.L. SHAPER et al.

Figures and 2 Venous phase of the mesenteric angiogram, showing the varix in the right side of the abdomen and pelvis.

MASSIVE COLONIC HAEMORRHAGE 255

through these, into the caecal wall was a 2 cm diametervarix. The portal vein pressure was 24 mmHg. A righthemicolectomy was performed.Examination of the specimen, which consisted of

22 cms ofterminal ileum and 13 cms ofcolon, revealeda lcm diameter tortuous vessel running alongside thecolon within the pericolic fat. At the caecum it passedthrough the muscularis propria to form a 2 cm diam-eter varix within the submucosa, opposite the ileo-caecal valve. The overlying mucosa was intenselycongested and nodular, but no definite ulceration orperforation into the varix could be identified macro-scopically.

Microscopically the varix directly abutted themuscularis propria. Its wall was arterialized with theformation of irregular elastic laminae and smoothmuscle bundles. The mucosa overlying the varixshowed early necrosis (Fig.3). There was markedcongestion and dilatation of submucosal veins in theadjacent small and large bowel. Bleeding was as-sumed to have arisen from the congested and necro-tic mucosa.

Postoperatively she was transferred to ITU, andhad no further GI blood loss. She developed acuterenal failure, requiring haemofiltration and progres-sive liver failure. At nine days postoperatively shedeveloped a series of cardiac tachyarrhythmias that

were unresponsive to amiodarone and cardioversion.She became clinically septic and died 10 days post-operatively of multi-organ failure.Postmortem examination revealed acute tubular

necrosis, multiple infarctions in a cirrhotic liver, and asubendocardial infarct. It was considered that thesehad all resulted from the profound hypotension at thetime ofher massive GI bleed. There were no varices atother sites and no macroscopic evidence of a septicfocus.

DISCUSSION

This is the second well documented case ofmassive GIbleeding originating from a solitary caecal varix3. Inthis case the varix was associated with adhesions froma previous appendicectomy. This case differs fromprevious reports on variceal haemorrhage from postappendicectomy adhesions in that the varix was soli-tary, previous reports demonstrating multiple varicescommunicating between portal and systemic circula-tion, enlarged by the presence ofportal hypertension45.

Diagnosis of the cause of colonic bleeding can bedifficult. In this case the abnormal vein was seen onangiography, but no intra luminal contrast was appar-ent. This problem has been described before and is

Figure 3 Caecal varix abutting muscularis mucosae with overlying early mucosal necrosis. (HEVG x 100)

256 K.R.L. SHAPER et al.

probably due to the dilution of contrast which occurswhen imaging the venous phase ofan arterial injectionofcontrast and the intermittent nature ofthe bleeding.The site of colonic bleeding may therefore be betterassessed by labelled red cell scanning but neitherinvestigation is useful unless the patient is activelybleeding6. Management of patients with liver diseaseand massive GI haemorrhage is associated with a veryhigh mortality, mainly due to liver failure and sepsis.The absence of oesophageal varices and the normalsized spleen on angiography did not suggest the pres-ence of portal hypertension pre-operatively, althoughthis was confirmed by portal pressure measurement atoperation. The operative management for colonicvarices falls into two groups-colonic resection andportosystemic shunting. These therapeutic modalitieshave not been directly compared, but an analogoussituation which has been studied is that of bleedingfrom oesophageal varices in which oesophageal tran-section has been shown to have a lower mortality andencephaopathly rate than portosystemic shunting7.However, with colonic variceal bleeding, bowel resec-tion has the advantage over shunting that it is anoperation done by the majority of general surgeons.

If portal hypertension can be confirmed pre-opera-tively then another treatment option is transjugularintrahepatic portosystemic shunt (TIPS). This has madean impact in the acute management of bleeding oeso-phageal and gastric varices secondary to portal hyper-tension but has not yet been applied to colonic varicealbleeding.

Liver transplantation was also considered with thedevelopment of liver failure. Although suspected sep-sis precluded transplantation in this case, it would be atreatment option after initial control of the colonicbleeding by TIPS and this combination may be theideal therapeutic option in patients with advancedliver disease and massive colonic haemorrhage8.

REFERENCES

1. Orozco H, Takahashi T, Mecando M, Prado-Orozco E, FerralH, Hernandez-Ortiz J, Esquivel E. (1992) Colorectal varicealbleeding. J. Clin. Gastro114 (2) 139-143.

2. Monare A.C, Waltman A.L, Vandersalm T.J, Linton R.R,Levine F.H, AbbottW.M. (1976) Gastrointestinal haemorrhagefrom adhesion related mesenteric varices. Ann Surg 183:24-29.

3. Patel K.R, Wu T.K, Powers S.R. (1979) Varices of the colonas a cause of Gastrointestinal haemorrhage. Dis ColonRectum, 22: 321-323.

4. Bloor K, Orr W. (1961) A case of haemorrhage from varices inthe small intestine due to portal hypertension. Br JSurg, 48: 423.

5. Manzi D, Samanta A. (1985) Adhesion related colonic varices.J Clin Gastroenterol. 7: 71-75.

6. Gudjonsson H, Zeder D, Gameli R.L, Kage M.D. (1986) Co-Ionic varices. Report of an unusual case diagnosed byradionuclide scanning with a review of the literature. Gastroen-terology. 91: 1543-1547.

7. Osborne D.R, Hobbs K.E.F. (1981) The acute treatment ofhaemorrhage from oesophageal varices: a comparison ofoesophageal transection and staple gun anastomosis withmesocaval shunt. Br J Surg. 68: 734-737.

8. Ring E.J, Lake J.R, Roberts J.P, Gordon R.L, LaBerge J.M,Read A.E, Sterneck M.R, Ascher N.L. (1992) Using transju-gular intrahepatic portosystemic shunts to control varicealbleeding before liver transplantation.Ann Int Medicine 116: (4)304-309.

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